Saturday, October 14, 2006

Demystifying PICU, part 2: Chaos Theory

So, you've had some very bad luck and your son or daughter has been admitted to PICU.

What you see when you get here will likely dismay you at first. After that has subsided, most people we talk to profess relief that they are in critical care. They figure, if they're going to have to go through this ordeal, they'd rather go through it with as many experienced people around as possible. All our resources and equipment concentrated in one spot.

The trouble with having all that cool stuff: lots of technology, and lots of people, is that the more interactions you concentrate into a small space, the more chaotic it seems. We're like ants, or bees: we swarm, and it can all happen very quickly indeed. I wish we were better at it. One PICU even worked with Ferrari's pit crew to improve their routine. Maybe they'll come up with something good, but in the meantime it's chaos.

In their own way, the child creates their own chaotic locus. Their anxiety, distress, difficult breathing, low blood pressure or whatever has caused this admission demands an answer, now, and the PICU ant swarm must assemble its response! We try to create order from their chaos, first of all.

Because of this, one of the first things you may see us do is sedate your child. People react in different ways to this. Some are glad to see their son or daughter finally get some rest, albeit enforced. Others are frightened when they see how still their child has become. Often you will notice our work seeming somewhat more organised at this time, because we no longer need to restrain or distract the patient.

Depending on how sick your child is, you may see a great deal more activity. It's not uncommon for us to have three nurses and two doctors working with the same patient, not to mention all the extra people like radiographers, consultant physicians, surgeons, anaesthetists, a transport team, maybe a social worker and a ward clerk thrown in there for good measure. During all of this we may occasionally lose sight of our need to keep you informed. For the most part we try not to, but sometimes we don't know ourselves what to say yet. Sometimes it really is better to step out into the hallway for a few minutes, grab some water and take a few deep breaths.

Usually there are people ducking and weaving around each other as they reach for a pump alarming, the ventilator, a peripheral line, a chest drain, or whatever else they need to work with. It's a clumsy kind of dance, people in pyjamas pirouette and bow as they negotiate the throng. Sometimes I wish I could watch it from above... one of these days I'll install a camera on the ceiling.

Thankfully, in PICU chaos is fleeting. Sooner or later the pyjama dance is over and the bodies at the bedspace drift away. There should be a plan for the next few hours in place. The bedside nurse will still be working through various jobs but she will have time to talk again while she's doing them. Hopefully the PICU consultant will also have extricated herself from the ten different conversations she's been having with various teams, trying to arrange the next steps in the process, and can sit down to chat with you about what's just happened.

Don't be surprised if you don't remember a thing about all this. Chaos does funny things to a person's memory.

I once talked to a dad several days after his son's admission to PICU. He said he couldn't remember the helicopter ride, couldn't remember arriving to the hospital or much of anything about the first hours of admission. The only thing he could recall with any clarity was the big ugly soft toy singing nursery rhymes a nurse was using to get another baby to sleep.

Next week: Access All Areas.
(Last week: Ventilator, Schmentilator.)
Posted by PaedsRN at 4:45 PM

Blogger Laura, at 8:36 AM  

great description of PICU from a parent's perspective.
I did have the misfortune of being a parent in a PICU when my then 8 y/o was brought in from a 6 ton truck versus pedestrian trauma. IT was scary as hell for me.
The last time I crossed that PICU threshold was as a nursing student. I wasn't ready for this as a mom....and I wasn't quite ready to take off the nurse cap either as I questioned the morphine does ordered (too much as darling daughter didn't weigh 80 lbs, try 45) and I barked at the med student. Daughter's nuirse assured me that if I hadn't have spoken up she would have. She, and everyone else was awesome caring for my daughter and keeping me from spontaneously combusting.
How is daughter today? 5 years later she is hppy, helathy, one would never know about her adventure and she has no memory of it. I wish it was so easy for me to forget. Still I give thanks.

Blogger Susan, at 1:39 PM  

I agree- a good description. My son his been in PICU several times post-surgery. He was transported across the street from the table straight to the PICU by ambulance.

Each time I was made to stand outside the room. I could't even look through the window. That is the only thing that I take issue with. Why can't I stand in the corner and watch? I suppose they have had parents in the way too many times but I still think it is my right as a parent to be in the room with my child or to at least be able to observe him.

It sounds like your PICU does allow parents to observe while the child is being admitted. Thanks for being sensitive to that.

Blogger PaedsRN, at 5:27 PM  

Only on very rare occasions will we actively kick parents out of the room. I can only think of one where we always do, and that's operating to close an open chest. Even then I suspect if a parent spoke directly to the surgeon, they might be able to stay.

We're really keen on keeping parents at the bedside wherever possible. These policies do vary from center to center though.

Laura, we don't let medical students 'prescribe' anything for our kids! Actually, they hardly get a chance to get near except in carefully supervised groups. We're a little better with nursing students, who get buddied placements working directly with patients.

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